If I collected a penny every time someone said that they had broken their wrist because they had fallen hard, I would have broken my piggy bank. Fracturing a bone when you fall is not normal. Your bones should not break when you fall.
Think of a piece of plastic when it is new. Although it is rigid, it still has some give to it. Over time, plastic tends to lose its bending ability so that it becomes more prone to crack. Bones are similar. With aging, bone becomes less bendable and more fragile. The force from a fall causes older bone to crack and fracture.
An arm or wrist fracture is a big red flag. It means that you are at risk for more fractures in the future—literally, a cascade of fractures. But fractures are not inevitable; by acting now you can prevent future fractures from happening. Recognition of risk is the first step. Unfortunately, the majority of people do not put two and two together.
A large international study of over sixty thousand women illustrates this point. In the Global Longitudinal Study of Osteoporosis in Women (GLOW Study), women from ten different countries in Europe, North America, and Australia were asked about awareness of osteoporosis. All were postmenopausal, with an average age of sixty-nine. Only one in five women thought her risk of osteoporosis was higher than other women of the same age.
The majority of women participating in the study who had been diagnosed with osteoporosis did not recognize that their condition could result in fractures. In fact, most of the women taking osteoporosis medicines did not think they were at high risk for fractures. Because they were being treated for the disease, they figured that they were in the safe zone and had the same level of risk for fractures as those who did not have osteoporosis. How wrong they were!
Osteoporosis is referred to as a silent disease. Fractures can break that silence. Interestingly, you may not even know you have had a fracture. Silent fractures occur in the spine. Most other fractures are caused by a fall. Fractures can have devastating consequences; they can lead to serious disability, and, yes, even death. The goal is to prevent fractures in the first place.
Based on the latest figures, more than two million adults break bones each year. Men account for 595,000 or 29 percent of the fractures. Although Caucasian men and women are predominantly affected, one in five men and one in eleven women are non-Caucasian.
Hip, spine, and wrist fractures are the classic fractures characteristic of osteoporosis. Fractures that include upper arm, rib, collarbone, kneecap, and lower leg are other sites of skeletal fragility. Of all fractures, the ones classified as “other” make up the largest proportion. Hip fractures that occur in the proximal femur, which is the bone between the hip and knee joints, account for one out of every seven fractures.
Fractures are costly. In 2005, the costs for new fractures in the United States were estimated at $17 billion. Hip fractures account for nearly three quarters of all fracture costs. Some projections show that hip fractures will be the top consumer of our healthcare dollars spent on the sixty-five and older age group. Already hip fractures account for about 20 percent of Medicare claims. The projected costs for more than 3 million fractures in 2025 are estimated at $25 billion.
A tsunami of fractures is expected with the graying of baby boomers. It is estimated that 40 to 50 percent of postmenopausal women and approximately 25 to 33 percent of men will eventually sustain a fracture. The numbers of fractures associated with low-energy falls are increasing with the expanding size of our aging population. Fractures of the hip and spine dramatically increase with age for both men and women. The rates of wrist fractures level off in women as they age.
HIP FRACTURES
Hip fracture is the granddaddy of all fractures. The majority occur in individuals over age seventy-five. More than 40 percent occur in the eighty-five-and-over age group. If you are younger, hip fractures are usually not an immediate danger. The difficult part about prevention is thinking so many years ahead.
Everyone seems to have a story about an older relative or friend who had a hip fracture:
“It was the beginning of the end.”
“My grandmother never walked again.”
“My grandfather never made it out of the hospital.”
“My mother never recovered and died in a nursing home six months later.”
Being in the hospital for whatever reason at an older age is fraught with danger. Major surgery, including repairing your broken hip, can result in disaster. Unfortunately, our organ systems in later years just do not have the reserve we have as younger adults. Older adults walk a balance beam without knowing it. Surgery knocks you off balance. Then it is a domino effect. One system goes, then another and another.
You want to avoid hip fractures in your golden years because you have a good chance of dying if you do have a fracture. Within one year of a hip fracture, 33 percent of men and 22 percent of women have died. Few medical diseases have such a high death rate. Hip fractures are killers.
Survivors after a year continue to have a higher death rate than their peers for ten or more years. Surviving does not equate to the same lifestyle as before the hip fracture. You are more likely not to return to your own home, but to instead end up in other residences that provide assistance.
YOUR STORIES…
Joan, age seventy-seven, got up early one morning to let out her dog. It was not quite light and she hadn't put on her glasses. She walked into her kitchen and hit a puddle of water from the dog's bowl, and her bare feet went out from under her. She landed hard on the tile floor with all of her weight on her right side.
Diagnosis: Hip fracture.
Fall-proofing your home will help decrease the likelihood of events like this.
SPINE FRACTURES (ALSO CALLED VERTEBRAL)
Not all fractures speak up. Only 20 to 30 percent of spine fractures are associated with a symptom, usually pain. These are called clinical spine fractures since they come to clinical attention. The ones that remain silent and are only identified through some type of x-ray imaging are called spine deformities or morphometric fractures.
No sex differences are observed in spine fractures. For both men and women, 27 percent of all fractures occur in the spine.
Spine fractures do not grab your attention like hip fractures. Few people end up in the hospital. Yet spine fractures may also have a tremendous impact on your life. You may have the image of a bent over older woman with a so-called dowager's hump or kyphosis. However, the majority of spine fractures may have only subtle clues, if any.
Height loss of two inches or more may indicate an underlying fracture. Back pain may be associated with a new fracture. In my experience, the patients who presented with back pain due to a fracture usually had a cause. They would report events such as: “I moved a heavy box of books”; “I lifted my grandson out of the crib”; and “I picked up a computer tower from under my desk.”
The spine is made up of three regions: neck or cervical, trunk or thoracic, and low back or lumbar. Fractures do not occur evenly along the spine. The most common locations for spine fractures are below the shoulder blades (T7-8), the last two levels of the thoracic spine (T11-12), and the first two lumbar levels (L1-2). The curvature of the spine may contribute to fractures occurring in these locations. The transition from a rigid midback to a more mobile lower back may be another factor.
Once one spine fracture happens you are likely to have more. Your risk of a second spine fracture is highest in the year following your first. A spine fracture is also predictive of fractures occurring at other sites.
YOUR STORIES…
Anne, age sixty-nine, returned home exhausted and with back pain after spending several weeks at her daughter's house. The occasion of the visit was the birth of a granddaughter. It was a joyous time, but she was on the move all day and all night. Not only was she helping with the new baby, her biggest task was trying to keep up with her twenty-month-old grandson.
One time, she picked up her grandson after he had fallen and skinned his knee. Afterward, she felt intense lower back pain. She was almost incapacitated, but she managed the pain, until finally, six weeks later, she was forced to see her doctor. An x-ray revealed a fracture of her first lumbar vertebra. He prescribed physical therapy to help with pain relief, as well as to improve her body mechanics for lifting and other activities.
Having one spine fracture puts her at high risk for another fracture. Once her pain subsides and she can lie comfortably, a bone density scan will be scheduled. Examining all her risks and laboratory tests to look for common other causes of fracture is also planned before treatment is started.
WRIST FRACTURES
Fractures of the wrist follow an opposite age trend from hip fractures. Wrist fractures are more common in younger men and women (ages fifty to sixty-four) and then rates level off and decrease with aging.
The reason for the reverse age trend is reflexes. With an unexpected trip or fall, younger people are more likely to stick out their arm to break the fall. Although their wrist may break, the rest of the body is out of harm's way. Later, with aging, your arm does not get out fast enough, and whatever body part lands first gets the brunt of the forces and is at risk for breaking.
Women are almost two times more likely to break their wrists than men. The reason for the difference between the sexes is structure. Men have larger bone size than women. Larger bones are harder to snap than smaller bones.
Wrist fractures should have a big warning sign attached to them. If you have a wrist fracture, you have a two- to fourfold risk of fractures at other sites. Wrist fractures are your wake-up call. It's time to evaluate your risk and reduce your chances of another fracture.
Wrist fractures themselves may not be totally benign. In the Study of Osteoporotic Fractures, women over sixty-five who had wrist fractures showed significant functional decline. The activities of daily living that were compromised included meal preparation, heavy housekeeping, ability to climb ten stairs, shopping, and getting out of a car. The researchers equated the impact of wrist fracture in older women to those seen with other established risk factors for functional decline such as falls, diabetes, and arthritis.
SHOULDER FRACTURES
A shoulder fracture is of the upper arm or the bone called the humerus. The fracture of the shoulder is closely linked to hip fractures because the fall is similar. With a sideways fall, the shoulder hits first instead of the hip.
In fact, hip fractures are common within the year after shoulder fractures. A high risk of hip fracture follows a shoulder fracture. The risk decreases with time but remains higher than the risk for the general population of the same age. If a shoulder fracture occurs, you need to be proactive and do everything you can to prevent a hip fracture.
OTHER FRACTURES
Fractures of the ribs, lower leg (tibia and fibula), collarbone, and kneecap are classified in the “other” category. Recent research has shown that these fractures are related to underlying osteoporosis, whereas in the past they were not considered to be a result of a fragile skeleton.
These other types of fracture account for the most common fractures in men, at 44 percent, and women, at 29 percent. They tend to be less severe, except that the pain with a rib fracture can be quite severe.
In the Osteoporotic Fractures in Men (MrOS) Study, rib fractures were the most common clinical fracture. Half of rib fractures were associated with a fall. In addition, men with rib fractures had classic risk factors for osteoporosis, including older age, low hip bone density, and history of fracture. A history of rib fracture predicted more than a twofold increase in risk of future fracture of the rib, hip, or wrist.
Interestingly, an ankle fracture in both men and women does not show the usual relation to age and bone mineral density as seen for other fragility fractures. However, the severity of many ankle fractures may be magnified by underlying skeletal fragility.
FRACTURES BEGET FRACTURES
The problem is that once you have one fracture the probability of another fracture is quite high. The increase in risk is not constant over time. The critical time is the first year after fracture, as the highest number of refractures occur in the first year after the initial injury. Up to one-third of men and women fracture again within one year. Risk decreases over subsequent years, but remains higher than the general population's risk for beyond ten years. Men are at higher risk than women of sustaining a subsequent fracture at any site after any type of first fracture, with the exception of an ankle fracture.
DEATH
Overall a higher rate of death following a fracture is observed in men than women. Since osteoporotic fractures are less common in men than women, they usually reflect a poorer underlying health. Other illnesses might be the cause directly or indirectly of the fracture event itself and also contribute to a poorer outcome after fracture.
Hip Fractures Are Not the Only Killers
Spine Fracture. The risk of death differs for spine fractures between ones that come to clinical attention with symptoms and those that are silent and are found on x-ray. In addition to all the problems with symptomatic spine fractures, those who feel pain associated with the fracture have death rates almost as high as the death rate for hip fractures. This is observed in both men and women.
For silent spine fractures, the association between fracture and risk of death is less clear because a minority come to clinical attention. In one ten-year follow-up of men and women with spine fractures diagnosed by x-ray, the risk of death was approximately twofold higher compared with those who showed no evidence of spine fractures.
Shoulder Fracture. The patterns for shoulder fractures are more difficult to interpret. A slight but significant excess in deaths is observed, which decreases with time; at five years after injury the risk was no longer greater than that of the general population.
A decreasing risk of death with time is a common feature of hip, spine, and shoulder fracture. In a sample of older Australian men and women, increased risk of death persisted for five years for all major fractures and for ten years after hip fractures. Subsequent fractures were associated with an additional five years of elevated risk.
Wrist Fracture. After a wrist fracture, studies show a similar risk of death to that of the general population. However, researchers found that people in their eighties who suffered a wrist fracture tended to be more physically active and robust. They were still spry enough to stick their hand out to break their fall instead of suffering a hip fracture. Wrist fractures in the eighty-and-older age group may be associated with an even lower mortality rate than that of their peers.
CHILDHOOD FRACTURES
Childhood fractures are rising. Why? Is it because of more risky behaviors? Or are children less bone healthy? I believe it is both.
One of my “adopted” French sons, Eddy, along with his brother, competes in motorcycle races called Supermoto. At age fourteen, Eddy had a major crash and broke both legs. That's an extreme example, I will admit, but not necessarily among those athletes who compete in today's action sports events.
Some evidence suggests that unhealthy lifestyle is a major cause. Less physical activity leads to the production of fat in the bone marrow instead of production of new bone-forming cells. The majority of preteens and teens do not meet the daily calcium and vitamin D recommendations. These factors may lead to making less bone, which results in lower peak bone mass.
What are the long-term consequences of a childhood fracture? There is conflicting evidence. Some evidence shows that you never catch up.
BIOMECHANICS OF FRACTURES
Numerically, more fractures occur in those with low bone mass than in those diagnosed with osteoporosis. In the Study of Osteoporotic Fractures, older women who had hip bone densities higher than the osteoporosis cut-off accounted for more than half of the observed hip fractures. Many factors play a role beyond what is measurable in bone density. Among them is bone strength, which includes density, structure, and material properties. In addition, nonbone factors such as muscle strength and the likelihood of falling also play large roles.
A fracture occurs when the forces on the bone exceed its strength. The strength of the bone changes dramatically with aging. The microstructure of the bone becomes thinner and weaker. The geometry of the bone changes with thinning of the cortex and expansion of bone size. Forward bending movements increase the load on the spinal column and cause spine fractures. The impact of a fall to the side directly increases the force on the weaker bone and may result in a hip fracture.
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The Bare Bones
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